|
Date/Time (Flip on)
|
|
|
Yawning
|
Yawning
|
|
Rhinorrhea
|
Rhinorrhea
|
|
Piloerection
|
Piloerection
|
|
Perspiration
|
Perspiration
|
|
Lacrimation
|
Lacrimation
|
|
Mydriasis
|
Mydriasis
|
|
Tremors (Hands)
|
Tremors (Hands)
|
|
Hot and cold flashes
|
Hot and cold flashes
|
|
Restlessness
|
Restlessness
|
|
Vomiting
|
Vomiting
|
|
Muscle Aches
|
Muscle Aches
|
|
Abdominal Cramps
|
Abdominal Cramps
|
|
Anxiety
|
Anxiety
|
|
Total Score
|
|
|
Initials
|
|
|
B/P
|
P
|
|
* A Score of >3 is necessary for initial buprenorphine/naloxone adminstration.
|
|
